A nurse is administering a medication to a client. The nurse identifies the client has an allergy to the medication after it has been administered. Which of the following actions should the nurse take?
Notify the facility's risk management team.
Assess the client for a change in condition.
Place an incident report in the client's electronic medical record.
Administer an antidote before notifying the provider.
The Correct Answer is B
A. While it may be necessary to notify risk management eventually, the immediate priority is to ensure the client's safety and well-being.
B. The nurse should promptly assess the client for signs and symptoms of an allergic reaction and initiate appropriate interventions as necessary.
C. Documentation of the medication error and allergic reaction should be completed after ensuring the client's immediate needs are addressed.
D. Administering an antidote may be appropriate in certain situations, but the nurse should first assess the client's condition and follow established protocols for managing allergic reactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Povidone-iodine is not recommended for cleaning around the stoma as it may cause irritation.
B. Ensuring the pouch opening is slightly larger than the stoma helps prevent irritation and ensures proper fit.
C. Regular emptying of the ostomy pouch prevents leakage and skin irritation. It also prevents it from becoming too heavy and pulling away from the skin.
D. The nurse should advise the client to place a piece of gauze over the stoma while changing the pouch to protect it from injury and contamination.
E. A purplish-blue change in the stoma is an indication of impaired blood supply to the stoma and should be promptly reported to the healthcare provider.
Correct Answer is C
Explanation
A. The dropper should be held about 1 cm (0.4 in) away from the eye to avoid touching or injuring the eye or contaminating the dropper tip.
B. Massaging the eyelids after instillation is not a standard practice and may cause discomfort or injury to the eye.
C. Administering multiple ophthalmic medications requires a sufficient interval between doses to prevent interactions and ensure effectiveness.
D. Asking the client to close their eyes tightly may squeeze out some of the medication or increase intraocular pressure.
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